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The charge nurse is supervising unlicensed assistive personnel (UAPs). The charge nurse should immediately intervene when a UAP is observed
- A. assisting a client with multiple sclerosis to shower.
- B. applying a condom catheter to a client who is incontinent.
- C. transporting a client with myocardial infarction to the cardiac catheterization lab.
- D. obtaining vital signs for a client with delirium.
Correct Answer: C
Rationale: Transporting a client with myocardial infarction (C) by a UAP is unsafe, as they require continuous monitoring for cardiac instability. Shower assistance (A), condom catheter application (B), and vital signs (D) are within UAP scope.
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The nurse is conducting a staff education program about hand-off reports for clients in an acute care environment. Which of the following should be included during the hand-off report? Select all that apply.
- A. emergency code status
- B. allergies
- C. home medications
- D. admitting diagnosis
- E. review of previous hospitalizations
- F. health insurance status
Correct Answer: A, B, C, D
Rationale: Code status (A), allergies (B), home medications (C), and admitting diagnosis (D) are critical for safe care transitions per ISBAR standards. Previous hospitalizations (E) and insurance status (F) are not essential for immediate handoff.
The nurse is triaging phone calls at the physician’s office. The nurse should initially follow-up on the client who had
- A. cataract lens extraction one day ago and is reporting persistent nausea and vomiting.
- B. laparoscopic hysterectomy two days ago and is reporting pain with urination.
- C. ileostomy placement three days ago and is reporting that the stoma is swollen.
- D. total hip arthroplasty four days ago and refused physical therapy due to increased pain.
Correct Answer: A
Rationale: Persistent nausea and vomiting post-cataract surgery (A) suggest possible complications like increased intraocular pressure, requiring immediate follow-up. Dysuria (B), stoma swelling (C), and therapy refusal (D) are less urgent, as they are common or non-emergent.
The nurse is triaging phone calls at a clinic. The nurse should initially follow-up with the client who reports
- A. decreased libido while receiving prescribed dutasteride.
- B. swelling in their right leg while receiving prescribed tamoxifen.
- C. hot flashes and night sweats while receiving prescribed letrozole.
- D. bone pain while receiving prescribed filgrastim.
Correct Answer: B
Rationale: Right leg swelling on tamoxifen (B) suggests deep vein thrombosis, a life-threatening emergency requiring immediate follow-up. Decreased libido (A), hot flashes (C), and bone pain (D) are expected side effects and less urgent.
The nurse is caring for the following assigned clients. It would be a priority to follow up with a client who
- A. has atrial fibrillation and a heart rate of 112/minute.
- B. has glomerulonephritis with a blood pressure of 137/86 mm Hg.
- C. is receiving amphotericin B, and the most recent temperature is 100.4°F (38°C).
- D. has chronic obstructive pulmonary disease (COPD) with an oxygen saturation of 91% on room air.
Correct Answer: A
Rationale: Atrial fibrillation with a heart rate of 112/minute (A) indicates a rapid ventricular response, risking hemodynamic instability or stroke, requiring immediate rate control. Glomerulonephritis with normal BP (B), mild fever with amphotericin (C), and COPD with 91% saturation (D) are less urgent, as they are stable or expected.
The nurse is providing discharge instructions to a client who speaks a language different from the nurse's. The client's family members are present, and they speak English. Which action by the nurse is the most appropriate to ensure effective communication during the discharge process?
- A. Use a smartphone translation app to convey the instructions to the client.
- B. Provide written material in the client's language and provide oral instructions in English.
- C. Request an interpreter from the hospital's language services to assist with the discharge instructions.
- D. Summarize the instructions in basic English and have the family members relay the information to the client.
Correct Answer: C
Rationale: Using a professional interpreter (C) ensures accurate communication, adhering to legal and ethical standards for discharge teaching. Smartphone apps (A) are unreliable, written material with English oral instructions (B) is ineffective, and relying on family (D) risks misinterpretation.